Precision Pharmacy: Positioning Clinical Pharmacists to Improve Patient Care through Genetically Guided Medication Selection

Transcription

1 Precision Pharmacy: Positioning Clinical Pharmacists to Improve Patient Care through Genetically Guided Medication Selection Rebecca Pulk Fellow, Center for Pharmacy Innovation and Outcomes 1

2 Acknowledgements Enterprise Pharmacy Jenna Carmichael Mike Evans Gerald Greskovic Laney Jones Melissa Kern Dean Parry Eric Wright Genomic Medicine Amy Strum Adam Buchanan Miranda Hallquist Mike Murray Marci Schwartz Marc Williams 2

3 Outline 1. Geisinger Resources 2. Genetic Information That Can Inform Medication Selection Precision Pharmacy 3. Applied Pharmacogenomics 4. Targeted Chemotherapy 5. Medication Management in Genetic Disease 3

4 Geisinger 4

5 Medication Therapy Disease Management: Collaborative Practice Areas Metabolic Disease Diabetes (inc. insulin pump oversight) Hypertension Hyperlipidemia Asthma / COPD Pain Management Neurology MS Neuroimmune Hematology / Oncology Heart Failure Anticoagulation Anemia Gastroenterology Hepatitis C Inflammatory Bowel Geriatrics Medically Complex Care 5

6 Genomic Information within Geisinger 6

7 Outline 1. Geisinger Resources 2. Genetic Information That Can Inform Medication Selection Precision Pharmacy 3. Applied Pharmacogenomics 4. Targeted Chemotherapy 5. Medication Management in Genetic Disease 7

8 Traditional Pharmacogenomic Markers Actionable Genetic Markers of Disease Pharmacogenomic Markers Tumor Specific Markers Actionable Genetic Conditions CPIC PharmGKB NCCN Drug Labeling ACMG list Geisinger 76 8

9 Precision Pharmacy Applied Pharmacogenomics Medication Management in Genetic Disease Targeted Chemotherapy 9

10 Applied Pharmacogenomics 10

11 emerge Pharmacogenomic Results Gene Variants Drugs Affected Gene Variant Drugs Affected 1. Welcome CYP3A5 rs Tacrolimus CYP2C19 rs (*2) Clopidogrel 2. Progress Update CYP2C9 rs (*2) Warfarin rs Escitalopram 3. Discussion Topics rs (*3) rs (*4) Citalopram VKORC1 rs rs (*3) Sertraline Single Gene Vs PGx Panel Testing TPMT rs Thioguanine rs (*5) Voriconazole Medication: Gene Pair Implementation Priorities rs Mercaptopurine rs (*6) 4. Next Steps rs Azathioprine rs (*8) Q Goals rs rs (*17) Working Group Deployment DPYD rs Capecitibine SLCO1B1 rs Simvastatin rs FU INFL3/4 rs Interferon α s rs Ribavirin 11

12 Ultimate Goal of Geisinger PGx Program Pharmacogenomic information available to improve medication related outcomes for our patients Available at time of Prescribing Integrated with EHR with intuitive clinical decision support Clinical Decision Support Modules Pharmacists Act as System Pharmacogenomic Experts Population Monitoring Through Real Time Registry 12

13 Targeted Chemotherapy 13

14 IJP volume 43, pages (2011) 14

15 Oral Chemotherapy Management Program Pharmacist led telephonic service serving a panel of 800 Geisinger Oncology Patients Double-check Medication Selection Patient Provided Education Ongoing Monitoring Compliance Support Conduit with Remaining Team 15

16 Medication Management in Genetic Conditions 16

17 Importance of Medication Management in Genetically Identified Disease Medication Avoidance Treatment Chemoprevention 17

18 MyCode Actionable Genetic Diseases: Organized by Medication Implications CDC Tier 1 Genomic Conditions Genomic Pharmacy Pharmacist Role Conditions # Genes Management: MTDM Familial Hypercholesterolemia 39 LDLR, APOB, PCSK9 Chemoprevention: Oral Chemotherapy Medication Avoidance: Genomic Pharmacy Service Hereditary Breast Ovarian Cancer 100 BRCA1/2 Lynch Syndrome 33 MLH1, MSH2, MSH6, PMS2 Malignant Hyperthermia 16 RYR1 Arrhythmias 26 SCN5A, KCNE1, KCNQ1, KCNH2 Marfan Syndrome 3 FBN1 Cardiomyopathy 53 MYH7, MYL3 MYBPC3, TPM1, TNNT2, TNNI3, Arrhythmogenic Right Ventricular Cardiomyopathy 3 DSP, PKP2, DSG2 Hereditary Thoracic aortic Disease 9 ACTA2 18

19 Implementation Designed to Build Evidence and Improve Patient Outcomes 1. Pharmacists are medication experts! Genetic results can inform prescribing, another data point Serve as a reference for patient and providers Proactive assessment of medication-related risk 2. Acting on available evidence is better than not acting at all. Documentation allows for continual improvement and creation of evidence Develop from emerging technology Standard of care 19